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↵∗Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University School of Medicine, 166 Gumi-ro, Bundang, Seongnam, 463-707, South Korea

Patients with ST-segment elevation myocardial infarction (STEMI) initially presenting to non–percutaneous coronary intervention (PCI)-capable hospitals are frequently transferred to PCI-capable hospitals, and consequently, they have longer total ischemic time and worse outcomes. Potential targets for reducing the first medical contact (FMC)-to-device time include the length of stay at the referral hospital (door-in door-out time), the transfer time, and door-to-device time at the PCI hospital (second door-to-device time). The smartphone social network system (SNS) is widespread and enables rapid, accurate communication among users. In a regional STEMI network, we initiated a STEMI hotline with or without use of a smartphone SNS application among the health care providers and evaluated whether SNS use can reduce the ischemic time.

We prospectively enrolled all consecutive STEMI patients who were transferred to our hospital (H2) from 16 non–PCI-capable hotline hospitals from July 2014 through December 2015. Among them, 5 hospitals participated in SNS activation, and the health care providers installed a smartphone application (BAND; Naver Corporation, Seoul, South Korea). In case of SNS use, the emergency physician at the non-PCI hospital unidirectionally activated H2 with a smartphone SNS application along with brief information (patient name, sex, pain onset, and estimated departure time) and a picture of the electrocardiogram taken by a smartphone camera. The interventional cardiologist at H2 reviewed the electrocardiogram and decided whether to group-page the catheterization laboratory team. In most cases, the team arrived at the hospital before the patient’s arrival to the emergency department at H2. The primary endpoint was the second door-to-device time between patients with and without SNS use, stratified by arrival time. The institutional review board of Seoul National University Bundang Hospital approved the current study.

One hundred fourteen STEMI patients were transferred from non-PCI centers. The median age was 61 years, 76% were male, 21% had diabetes mellitus, and 39% had hypertension.

SNS was used for 50 patients (44%), and they had a shorter median second door-to-device time than those without SNS use (47.5 min, interquartile range [IQR]: 40 to 56 min vs. 56.5 min, IQR: 47 to 69.5 min; p < 0.001). Among patients arriving during weekdays, there was no difference in second door-to-device time between those with or without SNS use (47 min, IQR: 41 to 54 min vs. 51 min, IQR: 43 to 57.5 min; p = 0.184), whereas during off-hours, it was shorter for patients using SNS (49 min, IQR: 39 to 56 min vs. 64.5 min, IQR: 56.5 to 75 min; p < 0.001). Interestingly, the second door-to-device time of STEMI patients transferred during off-hours could be reduced to the level of those transferred during weekdays (Figure 1A).

(A) Patients with social network system (SNS) use had a shorter median second door-to-device time. The second door-to-device time of patients with ST-segment elevation myocardial infarction transferred during off-hours could be reduced to the level of those transferred during weekdays. (B) The first medical contact-to-device time was shorter when SNS was used. FMC = first medical contact.

The 5 hospitals in the STEMI hotline group transferred 74 patients; of them, 50 patients (67%) used SNS. Their characteristics were similar to 24 patients without SNS use, except for fewer with a previous history of PCI (10% vs. 33%; p = 0.014). The median door-in door-out time was numerically shorter with SNS use (31 min, IQR: 20 to 46 min vs. 43.5 min, IQR: 22.5 to 73.5 min; p = 0.341). The median transfer time was similar between patients with and without SNS use (22 min, IQR: 17 to 34 min vs. 24 min, IQR: 20 to 35 min; p = 0.463). The FMC-to-device time was significantly shorter when SNS was used (102.5 min, IQR: 89 to 139 min vs. 129.5 min, IQR: 98 to 159 min; p = 0.031) (Figure 1B). The FMC-to-device time of ≤120 min was achieved in 62% and 46% with and without SNS use, respectively.

Approximately 50% of STEMI patients initially present to non–PCI-capable hospitals, and they have longer total ischemic time. The timeliness of reperfusion therapy for transferred STEMI patients begins at the referral center; SNS use allows for bypassing the search process for a PCI-capable hospital and enables a patient’s rapid triage. Especially, STEMI patients presenting during off-hours have higher mortality (1). This is partially attributed to the prolonged door-to-device time, because only a few hospitals have round-the-clock PCI capacity. Using SNS, the second door-to-device time during off-hours can be reduced to the level of presentation during weekdays. Finally, the median FMC-to-device time decreased substantially by 27 min, and the proportion of patients with FMC-to-device time of ≤120 min increased by 16%, which may potentially improve outcomes for transferred STEMI patients.

In conclusion, a network of local health care providers using a smartphone SNS may reduce the total ischemic time in transferred STEMI patients with rapid, seamless interactive communication among health care providers.

Footnotes

Please note: This work was supported by the Industrial Strategic Technology Development Program (10052980) funded by the Ministry of Trade, Industry & Energy; by Regional Cardiocerebrovascular Center Program of Korea Centers for Disease Control and Prevention; and by the SNUBH Research Fund (grant no 03-2011-011). The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Park and Yoon contributed equally to this work.

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